Provider Demographics
NPI:1851629851
Name:GILLIS, ASTOR CHARLENE (BS, LADC)
Entity Type:Individual
Prefix:MRS
First Name:ASTOR
Middle Name:CHARLENE
Last Name:GILLIS
Suffix:
Gender:F
Credentials:BS, LADC
Other - Prefix:MRS
Other - First Name:ASTOR
Other - Middle Name:CHARLENE
Other - Last Name:BILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:59 FRANKLIN ST.
Mailing Address - Street 2:SUITE B
Mailing Address - City:ELLSWORTH
Mailing Address - State:ME
Mailing Address - Zip Code:04605
Mailing Address - Country:US
Mailing Address - Phone:207-667-2730
Mailing Address - Fax:207-669-4027
Practice Address - Street 1:59 FRANKLIN ST.
Practice Address - Street 2:SUITE B
Practice Address - City:ELLSWORTH
Practice Address - State:ME
Practice Address - Zip Code:04605
Practice Address - Country:US
Practice Address - Phone:207-667-2730
Practice Address - Fax:207-669-4027
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC2639101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME256940099OtherMAINECARE